Stress test vs flipping a coin: which is more accurate?

You may not have any signs or symptoms of coronary artery disease while you are just sitting there quietly reading this post. In fact, your symptoms may occur only during exertion, as narrowed arteries struggle to carry enough blood to feed a heart muscle that’s screaming for oxygen under increased demand. Enter the diagnostic stress test, used to mimic the cardiac effects of exercise to assess your risk of coronary artery disease.

During stress testing, you exercise (walk/run on a treadmill or pedal a stationary bike) to make your heart work harder and beat faster. An EKG (also called ECG) is recorded while you exercise to monitor any abnormal changes in your heart under stress, with or without the aid of medications to enhance this effect.

But consider this blunt warning from Dr. Kevin Klauer:

“Exercise treadmill stress tests certainly aren’t perfect. Very few of our tests are. The key is not to consider their results in isolation. 50% of women and 25% of males with reversible perfusion defects detected by nuclear stress tests had a ‘normal’ exercise treadmill tests.”

Hoilund-Carlsen, P.F. et al, Am J Card 95:96, January 1, 2005

Dr. Klauer adds that despite clear clinical guidelines about using stress tests, concern and confusion apparently exist among physicians, according to hisSpecial Report: The Truth About Stress Teststhat heco-authored for the journal, Emergency Physicians.

For instance, he cites guidelines from the National Institute for Health and Clinical Excellence that state:

“Do not use exercise EKG to diagnose or excludestable angina* for people without known coronary artery disease.”

“The stress test can only help to diagnose coronary artery disease (CAD) that is producing partial blockages in the arteries – so-called obstructive CAD. But CAD often produces plaque in the arteries that may not actually be causing obstruction, and these non-obstructive plaques can (and do) rupture, causing acute blood clot formation, which produces an acute obstruction of the artery, often leading to myocardial infarction (heart attack).

“So it is certainly possible to have a ‘normal’ stress test while still having CAD.

“In some patients, EKG changes can occur even in the absence of CAD. (In other words, ‘false positive’ stress tests are not uncommon.) In other patients, no significant EKG changes are seen even in the presence of CAD. (So ‘false negative’ stress tests can be seen.)

“False positive and false negative studies can significantly limit the usefulness of the stress test in many patients.

“By adding a nuclear perfusion study to the stress test, this limitation may be minimized, and the diagnostic capacity of the stress test is greatly improved.”**

It almost seems counter-intuitive, but preventive cardiologists like Dr. Seth Baumconfirm that most heart attacks actually happen in what is called non-obstructive CAD (i.e. in vessels that are less than 70% blocked). He adds:

“This actually is one of the reasons why stress testing is such a bad screening test.

“Stress tests detect lesions that are greater than 70%. If an individual has multiple 50% blocked arteries, you’re going to miss that on a stress test, yet that individual is likely at significant risk for a future cardiovascular event.”

And speaking of both false positive and false negative results, Kentucky electrophysiologist and writer Dr. John Mandrolahas this to say about cardiac stress tests:

“Many non-cardiac conditions can cause the heart to look as though it is having trouble when it is actually not – things like abnormal electrolytes, fluctuations in blood pressure, breathing too fast, and certain medications. Not surprisingly then, false positive stress tests are a common problem.

“The opposite problem also occurs. False negatives happen when the stress test fails to reveal a potentially dangerous blockage. The supply/demand challenge of stress tests only identifies major blockages. But, the vexing way heart disease works is that most often it is the minor – not major – blockages that cause heart attacks or sudden death. Stress tests can’t see these minor blockages.

“The next sentence is not a typo:You can pass a stress test and have a major heart attack the next day.”

And cardiologist Dr. Martha Gulati, director for preventive cardiology and women’s cardiovascular health at the Ohio State University Medical Center, warns:

“What is surprising is the fact that all the research that describes stress testing, and that has gone on for more than 40 years, was done only on men.”

More recently, some researchers who have specifically studied accuracy in stress tests for female patients have made some interesting observations unique to women. For example:

In pre-menopausal women, EKG results taken during exercise appear to vary with the women’s menstrual cycles. (2)

Post-menopausal women receiving oral estrogen therapy are more likely to have exercise-induced EKG changes than post-menopausal women who aren’t on estrogen replacement(3).

Women are generally older when they undergo stress testing and may have decreased exercise tolerance, limiting the ability to accurately identify women with coronary artery disease (4)

Here’s how the National Heart Lung & Blood Institute lists the most common types of stress tests (and for a glossary of cardiac terminology, visit my patient-friendly, jargon-free glossary of cardiology terms and abbreviations):

Exercise echocardiogram or exercise stress echo

Exercise test

Myocardial perfusion imaging

Nuclear stress test

PET stress test

Pharmacological stress test

Sestamibi stress test

Stress EKG (or ECG)

Thallium stress test

Treadmill test

One of the most serious concerns about tests that are commonly used despite important diagnostic accuracy issues is that, as in my own case when first presenting to the Emergency Department, an initial “normal” test may lead to misdiagnosis.

No further tests will be ordered.

Physicians like Duke University’s Dr. Pamela Douglascall this phenomenon “verification bias”. As she warned in her editorial called “Is Non-invasive Testing for Coronary Artery Disease Accurate?” in the journal Circulation:(5)

“Patients with positive tests are more likely to have their results verified with further testing, while those with negative tests are rarely referred for subsequent studies. False-negative results are unlikely to be discovered, and true-negative results will be less likely to be confirmed and therefore will be underrepresented.

“For every cardiovascular non-invasive test analyzed for the effects of verification bias (exercise ECG, exercise thallium, exercise radionuclide angiogram, and exercise echocardiography), results are similar, according to research by Roger et al.

“No type of test escapes this verification bias effect.”

Dr. Douglas then added that, in populations with sex-based differences in disease prevalence and extent, there will be sex-based differences in the accuracy of test results:

“This suggest that test results must be analyzed in a sex-specific fashion and that the decision to proceed to the anatomic gold standard of angiography must take into account sex-based differences in measures of test accuracy.”

“The stress test is the elemental unit of diagnostic cardiology, and patients know of stress tests all too well. Unfortunately, both doctors and laypeople have been taught and trained wrong.

“I, for instance, was trained to believe in the general utility of stress testing. This was wrong. I was taught to obtain a stress test history, and to be comforted by normal results. Also wrong. I was taught to believe in the power of stress tests to establish safety and identify disease in low risk chest pain patients before they leave the hospital. Wrong.

“Sensitivities and specificities for stress tests are often reported as being between 70% and 90%, but these numbers are misleading. Studies of stress tests have rarely used a proper gold standard (i.e. coronary angiography), and in the one reasonably sized, high quality study to be performed rigorously, the test’s sensitivity for coronary stenosis was only 45%.”

♥

.* stable angina:chest pain or discomfort that comes on with exertion and lessens during rest, due to poor blood flow through narrowed or blocked coronary arteries
*See my glossaryfor no-jargon, patient-friendly definitions of cardiac terminology

97 thoughts on “Stress test vs flipping a coin: which is more accurate?”

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My mom had a nuclear stress done week ago. She continues with shortness of breath and now needing oxygen at all times. Says her heart feels funny that some shortness of breath and just walking to bathroom. Heart rate is elevated at times. It beats fast and skips a beat what could this be? They keep diagnosing her with COPD, lungs are clear and no test has been done. Her breathing is getting worse with tightness in chest then heart rate drops but it stays over 109-144.

Hello Kimberly – your mom’s symptoms sound frightening, and it’s distressing to watch our mothers suffering. I’m not a physician so I’m unable to comment on her specific case. There are so many possible reasons for her symptoms. It sounds like she has been already diagnosed with COPD – Mayo Clinic has some useful information about this diagnosis that may be reassuring. Best of luck to you and to your mother …

My mom has been having shortness of breath with exertion. If she walks short distance and even taking a shower. Family doctor treatment was for COPD which has never been confirmed. I made her a cardiologist appointment and echocardiogram was done and nuclear stress test. First scan was without medication and they put oxygen on her because they noticed shortness of breath. Second test with medication in IV without oxygen she seemed fine. She was done with test and walked down long hallway to leave, was able to get in car. No shortness of breath after medication was given. Had no shortness of breath for 45 minutes and stopped at a store and she had to sit down and catch her breath before using bathroom. Her doctor didn’t understand why her breathing was better it should have been worse with this test. Nuclear stress test came back negative for blockages. Now he wants to do lung test. My gut still says it’s a cardiac issue. What should we do next. Demand catheterizaton to be sure.

Hello Kim – I’m not a physician so cannot comment specifically on your mom’s unfortunate shortness of breath symptoms but I can tell you generally that shortness of breath is a symptom in a number of both lung and cardiac conditions.

So much of medicine is simply trying to figure out what the problem is NOT, which is likely why the lung tests are being recommended. Not sure where you live, but where I am, patients cannot just “demand” catheterizations – a cath is an invasive procedure with some inherent risks which is why it’s not done as a routine screening tool. Your mother may have undergone pulmonary function tests as one way to confirm COPD diagnoses; if not, that could be why this is being ordered now. Best of luck to you and your mother…

I went to the hospital twice in 2016 with Chest, left arm pain. Light headedness. Had all the routine testing done. Blood work, EKG, echocardiogram, stress test. Then in January 2017 had a nuclear stress test. Followed up after that test with my Cardiologist on Feb 7 2017 and was told.. “you did great, I can’t believe you smoke because you did so well, you did 11 minutes on the treadmill and reached good numbers that we needed with no problem. I don’t see any cardiac issues so I’ll see you in a year unless you have any problems.”

Well one week later on Valentine’s Day I had a heart attack in the shower. Find out I had 4 blockages at 30,70,90 and 100% with collaterals. Day later had a triple bypass at 52 years old.

So to me, I wouldn’t ever trust a stress test not because they missed it, but because the person reading it missed it!! So maybe it’s lack of training or lack of taking it serious that’s the problem and not the test itself. Another Cardiologist “off the record” said they would have never read it as a normal study and it looked like I had damage from a prior event.

What a shocker that must have been, John! It is actually not uncommon for a heart attack to follow a ‘normal’ stress test – the culprit is usually the soft vulnerable plaques that can rupture suddenly and cause a major blockage, yes – even after everything looks perfectly “normal” on the EKG.

And it’s relatively easy, in hindsight, for that cardiologist who offered you the off-the-record diagnosis, after the fact, to get it right the second time!

Hello Kim – I’m not a physician so can’t comment on the specifics of your own case. Please contact your physician or kidney specialist to review all aspects of your condition and possible related treatments. I wish I could be more helpful during this stressful time for you…

Hi Carolyn, I just found this thread looking for information on coronary artery disease and stress tests. I hope you still see these replies! I’m a 41 year old woman who just got the results of my nuclear stress test — it showed a small “anteroseptal perfusion defect” which my family doc says could be evidence of a previous heart attack.

I had the test because about three weeks ago, I had an “episode” of intense nausea and radiating jaw pain, followed by a day or so of shortness of breath. I was at a conference, and didn’t think “heart attack” until I got home and my husband remarked that the symptoms sound like those described by women who experience CAD. All the symptoms resolved, and I feel well again – but clearly something happened, and my primary worry now is whether or not I’m a ticking time bomb. Despite a normal weight, a whole foods diet and a regular regimen of walking/hiking every day, I have familial HBP, a high heart rate, and two parents who had heart attacks before age 65 – so despite my age, I do have serious risk factors.

I’m assuming, from these results and my risks, that the logical next step would be to get an angiogram ASAP to check for blockages.

Now here’s the rub – my cave-dwelling county health provider has approved an appointment with a cardiologist – IN JULY, almost 3 months from now.

Hi Liz – I’m not a physician so cannot comment specifically on what your distressing episode of symptoms meant three weeks ago, but I can say, generally speaking, what a wise cardiologist once told me: “It’s hard to improve on symptoms that aren’t there.”

In other words, you seem to be feeling fine now, and it also seems that you’re already doing everything that women are advised to do if they were diagnosed with a confirmed heart condition and thus considered to be at risk. If you were seeing a cardiologist tomorrow instead of 3 months from now, I’m betting that this cardiologist would advise you to eat a heart-smart diet, exercise every day, maintain your healthy weight, etc. – as you are already doing. Possibly take a daily aspirin – maybe, maybe not?

It’s unfortunate that you’re now feeling like a “ticking time bomb” (I hate that metaphor – as it provokes worry-related ongoing stress hormones like cortisol and adrenaline that are bad for your heart health). What sounds encouraging to me is that you’re able to go hiking/walking every day without provoking angina symptoms (angina typically worsens with exertion, goes away with rest).

Unfortunately I can’t tell you if you should be getting an angio ASAP or not, or whether you’re wrong in thinking this case is urgent (and it’s good to keep in mind that angio is not a benign procedure – it is invasive and carries potential risk to the patient, which is why it’s not the first line of diagnostic test ordered in asymptomatic people).

What I can add is that IF your symptoms recur, then that is the time the needle moves to urgent. Best of luck to you…

Hi, Carolyn. Hopefully you are still responding to comments on this post. I understand you are not a physician; I am simply just looking for your opinion as you have extensive knowledge with cardiology.

I am a 27 y/o female; overweight; borderline-high cholesterol; great blood pressure (110/65); no diagnosis of diabetes; minor family history of heart disease.

I recently saw a cardiologist due to on-and-off mild chest pain. An echocardiogram was performed and was normal. The doctor then ordered an exercise stress test.
I could not complete the stress test due to shortness of breath. The nurse practitioner performing the test increased the speed and incline twice and then asked me if I would be ok with another increase and I said no. The test was stopped shortly after and I asked her if I was short of breath because I am out of shape and she said yes. She said everything looked great and to follow-up as needed, such as if symptoms persisted or got worse. I’m not sure if she said it to make me feel better or not, but she said she pushed me harder than normal. Which doesn’t make sense to me because why would she ask me about another increase then? I normally don’t get short of breath on a daily basis, such as normal walking or walking up the stairs in my home, which I’m assuming is a good thing.

What are your thoughts on this? Any feedback is appreciated. God bless and take care.

Hi Casey – YES, you knew what I was going to say (“I’m not a physician…”)

I can say generally however that it’s not unusual for people who are “out of shape” to become short of breath on a treadmill. That’s to be expected. Higher exertion when increasing both speed and incline induces shortness of breath far more than simply normal walking or going upstairs would. My only feedback is to try this experiment: see what you can do to get into better shape (e.g. do regular – daily – sweat-producing activities that will raise your heart rate (like walking as quickly as you can up a hilly street in your neighbourhood every day). Do a bit more each day and you’ll find it will gradually become easier with far less huffing and puffing. Check with your GP first if you are nervous about doing so, but there is generally no downside in getting into better shape especially at your young age. In fact, moderate exercise (not just slow walking, for example) has been shown in many studies to improve longterm cardiovascular health even more than implanting a stent. Good luck to you…

I am very confused with my nuclear stress test, when I got there they put in an IV, pushed in the dye made me drink 2 glasses of water took a couple pics then hooked up everything on me, I then got on the treadmill it wasn’t to difficult my legs hurt a bit because I have PAD. After a couple minutes they asked if I could make it 1 more minute that I was almost to my peak I said yes, the whole thing lasted maybe 4 minutes, then they took everything off, gave me a drink and took a couple more pics, the next day the nurse left a voice mail saying everything looked good come back in 4 months, after several calls I finally managed to get a copy of my test, it says I asked them to stop the test because I was out of breath, that’s a lie, the test also called for the stuff they use to speed up your heart but I never got that because they said I reached my peak, in 4 minutes at a medium walk, that doesn’t make sense, I’m 52 average weight , female, I have chest pains almost everyday, get dizzy can’t breath and pulse races for no reason, I’m very confused

I had a stress ECG and reached the required level for my age and was given the all clear. One hour later, I had a Heart Attack. I was then given a Angiogram which showed a right Major Coronary Artery was blocked. I had a stent fitted and later that day sent home.
Scary stuff.

ONE HOUR LATER!?! Gerald, that is an amazing example of how ‘passing’ an ‘all clear’ stress test doesn’t necessarily mean you aren’t on the brink of a heart attack! Hope you are doing much better these days…

Hi, I just had a stress test performed today. My doctor suggested another stress test because she was concerned that my heart rate did not decrease enough when I was at rest. My questions: is a second test with dye necessary and can anxiety cause my heart rate to not decrease? By the way I’m 56 – I think I’m post menopausal at this point.

Hello Virginia – I’m not a physician so can’t address your specific question about the necessity of that second stress test. I can say generally that anxiety could cause an increased heart rate, but your physician would be the best person to discuss these questions with. Best of luck to you…

Had a nuclear stress test late January 2017. Sat with cardiologist on February 7th 2017 and he said I have no cardiovascular issues. That my problem may be GI related. One week later on February 14th I went to hospital with moderate heart attack. Heart catheter showed all 4 arteries were blocked at 30, 70, 90 and 100 percent!! And yes I’m only 52 years old.
Had triple bypass done on February 16th. What good is a stress test when it doesn’t pick up those blockages? Or maybe it’s not the test but the person reading it.

John, you’ve captured the key frustration in relying on stress tests as sole predictors of future cardiac events because of the nature of soft, vulnerable coronary artery plaque – the kind that can rupture and cause sudden blockages. As this post explains: “Non-obstructive plaques can (and do) rupture, causing acute blood clot formation, which produces an acute obstruction of the artery, often leading to myocardial infarction (heart attack). So it is certainly possible to have a ‘normal’ stress test while still having coronary artery disease.”

In May of 2016 I suffered a Stress Induced Cardiomyopathy Heart Attack.😥 After spending 9 days in the hospital, I was sent home and told to do cardiac rehab. As of 10/2016 all my EKGs are normal and my ejection fraction went from 10% of the left ventricle to 50% of the left ventricle. A stress test was never done. My Dr. changes the subject when I tell him I’m still not feeling well. Neck pain, shoulder pain, fatigue, stomach pain!! Don’t know what direction to go…. 😥

Hi Debra – I’m not a physician so cannot comment specifically on your own situation, but I can tell you generally that Takotsubo Syndrome (I believe that’s what you’re talking about when you say stress-induced cardiomyopathy) is a challenging diagnosis at the best of times.

Although symptoms can exactly mimic those of heart attack, it’s very different from heart attack in a couple of ways. Most heart attacks are due to blockages/blood clots forming in the coronary arteries that can cause heart muscle cells to die, leaving the heart with permanent and irreversible damage. But the heart muscle cells in most patients with stress cardiomyopathy are only temporarily stunned (as illustrated by your EF drop to 10%) and, as also in your case, usually return to normal function (50%) shortly after the episode. Virtually all Takotsubo patients appear to have normal coronary arteries with no blockages or clots.

Because the heart muscle is not permanently damaged with this syndrome, patients typically make a complete recovery. I wrote more about this syndrome here. Your symptoms sound distressing and should be addressed whether they are heart-related or not. If your doctor “changes the subject” when you want to discuss symptoms, you might want to change doctors. Seek a second opinion to discuss medications like diuretics or others that help to address heart muscle contraction and/or abnormal heart rhythms just to rule out these issues. Best of luck…

False negative. 10 months later main artery is 90 some percent obstructed. 2 stents and minor heart damage. High cholesterol for decades. severe neck pain and spasms. Yet not ONE physician suggested it could be my heart although my medical history shows my dad having 2 open heart surgeries and died needing a third. .so very frustrating! Increased faith in the medical world. ..indeed!

Sorry you’ve had to go through all this, Faye. Frustrating for sure. Hope you are feeling better day by day (and also that you were referred to cardiac rehabilitation after hospital discharge). Best of luck to you…

I’m a 25 y/o female; about 3 months ago I developed upper abdominal and chest pain along with nausea/loss of appetite. After it being consistent for a few weeks, I went to urgent care. They ordered an EKG, chest x-ray and blood work, all of which came back normal. Fast-forward a few weeks, I followed up with my PCP who referred me to a GI specialist. He ordered a CT scan of my abdomen with and without contrast, which surprise surprise, came back clear. Went back to my PCP who referred me to a cardiologist (I actually saw the nurse practitioner at the clinic). The first visit was mostly talking/history-taking. An EKG was performed which she said was normal. Because of my age and risk, there weren’t many tests she was able to order, but she said she would be able to do an exercise stress test if I wanted. She warned me that with young women, most of the time the test shows abnormalities (I asked why and she said she honestly wasn’t sure). So she said that we could do the test but if there were any abnormalities, we may need to go down a road of further testing we may not need to (if it ended up being a false-positive). So I agreed and did the test. I think they got my heart rate up to 170 something I believe and the only issue I had with the test was being a little out of breath (which isn’t out of the ordinary as I’m not much of an exerciser and I’m a bit overweight), but nothing significant where I couldn’t complete the test, and I also sweated a good amount. To my surprise, the nurse practitioner said she saw no abnormalities and she really didn’t have an answer for me regarding the chest pain. I know I’m young and a female, but heart attacks/heart disease isn’t all that uncommon for my gender at my age. I forgot to mention that I have normal blood pressure, never smoked a day in my life but my cholesterol is slightly elevated. I know you’re not a physician, but do you think this chest pain is something I should be concerned about?

You’re right, Cassidy – I’m not a physician so cannot comment on your specific symptoms. I can say, however that heart attacks in women your age are actually NOT common at all. The reason that dramatic stories about women in their 20s having heart attacks are widely covered is that they are so statistically rare. The average age of a woman having a heart attack is 70. Consider that about 435,000 women in the U.S. have heart attacks annually; of these, only 35,000 are under 55, and the number under 30 is even lower. So what should you do? You can continue to worry, or you can do what every woman diagnosed with heart disease, young or old, is told: make every cardioprotective lifestyle change you possibly can, starting with losing weight and starting to build in regular exercise every day. There is simply no downside in living life as if you were at very high risk of heart disease – even if you’re not. You could also start keeping a symptom journal: write down the time of day, description of symptom, and what you were doing/eating/feeling in the hours beforehand, even the weather or anything that might influence such symptoms. See if you can spot a pattern. You might also be reassured by knowing that over 85% of people admitted to hospital for chest pain turn out to have non-heart-related issues. Here’s a bit more on other possible reasons for chest symptoms. Best of luck to you…

Hi, Carolyn. I appreciate your reply. Your statistics put me a bit at ease. But the fact that heart attacks at and around my age (while rare) can and do happen, that’s what makes me nervous. My biggest fear is that I somehow had/am having a silent heart attack(s) and the EKGs and stress test isn’t somehow picking it up. Maybe I’m just being paranoid, but it’s said that 2/3 of EKGs miss a heart attack, and young women are especially hard to diagnose. What are your thoughts on this?

Hi again Cassidy. I think you already know my thoughts on this. Again, I’m not a physician so have no clue if your symptoms are heart-related or not, but it seems that you do have a choice here: you can continue trying to convince yourself that you’ve been having a heart attack for three months, making yourself anxious and preoccupied and basically ruining your quality of life, or you can try to reduce the anxiety by not obsessing. A “silent” heart attack has few if any symptoms at all, which is why it’s considered silent. Ironically, chronic ruminating as you describe can actually be dangerous to your heart health. And while it’s true that EKGs may not always be accurate in confirming heart disease, they are simply one diagnostic tool in the large toolbox of cardiac tests you’ve had so far. Please read this or this to see if any of it fits for you.

Both are great articles, but none of them really fit me. I of course don’t want to be diagnosed with a heart attack or heart disease, it’s really just me saying, “I know something’s wrong with my body and I’m amazed that tests aren’t showing anything.” Don’t get me wrong, I am very, very thankful for negative results. I read a bit on your history, could you tell me more about your heart attack? When you were misdiagnosed the first time with acid reflux, did they do an EKG at the hospital? And when you say your symptoms got worse over a few weeks, what exactly got worse? Like, what was it that made you say, “I know something isn’t right.” and go back to the hospital? Sorry if I’m being annoying, you just don’t know how good it feels to hear a voice. I try and talk to my husband and family and they aren’t any help at all and say, “it’s all in your head.”

Cassidy, I feel uncomfortable being asked to continue reinforcing your conviction, despite all evidence to the contrary, that you are in the middle of an undiagnosed heart attack. Again, I’m not a physician, and based on results here, nothing I’m saying seems to be acceptable to you unless I can somehow confirm your insistence that your symptoms are heart-related. I really hope they’re not, and that one of the many other possible non-cardiac reasons for your symptoms will emerge to put your mind at rest. Please see your family physician to review all your symptoms.

Sorry if I gave you that impression. I wasn’t asking you to continue to reinforce my conviction. I understand you’re not a physician. I never said you were and I even stated that I know you’re not. As I mentioned, I’ve already gone and seen my physician. I thought it would be nice to get an outside opinion and hear ideas from someone who’s actually gone through this experience. You have all of these articles (and a whole website) regarding heart attacks, etc, so I figured you would have a little knowledge from your personal experience and research. My apologies. Take care and best of luck to you in the future.

I already did share several “ideas” with you, Cassidy, none of which you seem interested in (e.g. try keeping a symptom journal to see if you can detect a pattern, here’s a list of dozens of non-cardiac conditions that can also cause chest pain, etc. etc.) And yes I do have some knowledge I’ve gained from researching this specific topic for the past eight years (which is exactly why I know for a fact that NOT all chest pain means a heart attack) but I’m not a physician so couldn’t possibly diagnose you or anybody else online. It seems you might not be quite ready to entertain any other reason for your symptoms than the one and only one you have convinced yourself must be true for you. I know you’ve seen your family physician already, but if your medical team doesn’t suspect your heart, then it’s time to go back and discuss what else might be causing these symptoms, especially if they continue or worsen. I believe there’s nothing more I could tell you to encourage you to be open to all possible options. Good luck…

UPDATE

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